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In Stewart, we reviewed medical research on fibromyalgia, which often lacks medical or laboratory signs, and is generally diagnosed mostly on a individual's described symptoms.
Summary of this case from Moore v. BarnhartOpinion
No. 99-6132.
December 20, 2000.
Appeal from the United States District Court for the Northern District of Alabama. (No. 98-0067-CV-H-NW), James H. Hancock, Judge.
Before BLACK, BARKETT and FAY, Circuit Judges.
In this appeal we review the district court's affirmance of the Social Security Commissioner's decision denying disability benefits to Claimant Shelby J. Stewart ("Stewart"). Stewart argues that the Commissioner, acting through an administrative law judge ("ALJ"), erred as a matter of law in failing to accord adequate weight to the opinions and assessment of Stewart's treating physician. Stewart also contends that the ALJ, and subsequently the district court, erroneously focused on the lack of objective medical evidence supporting the treating physician's diagnosis. After reviewing the record, we conclude that the ALJ did not afford proper deference to the treating physician and that Plaintiff is entitled to compensation.
On August 11, 1994, Stewart filed an application for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. § 401, et seq. Stewart claimed disability due to auto-immune deficiency disease, connective tissue disease, undifferentiated collagen disease, and fibromyalgia-fibrositis. Her application was denied initially and upon reconsideration, so Stewart requested a hearing before an ALJ. The ALJ, H. Evins Hamm, conducted hearings on April 22, 1996, and August 12, 1996, and issued a decision denying benefits on September 6, 1996. Stewart requested review of the hearing decision by the Appeals Council of the Social Security Administration, but the Appeals Council denied and dismissed the Request for Review. On December 17, 1998, the district court affirmed the Commissioner's decision.
The ALJ found that Stewart met the disability insured status from December 15, 1993 through September 30, 1995 and has not engaged in substantial gainful activity since December 15, 1993. The ALJ also determined that, on or prior to September 30, 1995, Stewart suffered from fibromyalgia, hypertension, residuals from breast implant removal, mitral valve prolapse, chronic obstructive pulmonary disease, and non-severe depression and panic attacks, and that these conditions together constituted a "severe impairment" within meaning of the Social Security Act. However, the ALJ concluded that the record contained no objective clinical evidence of an impairment that met or equaled any impairment listed in Appendix 1, Subpart P of the regulations. See 20 C.F.R. § 404 (1999).
September 30, 1995, represents the date Stewart was last insured.
At the hearing before the ALJ, Stewart testified that she is 40 years old with a twelfth grade education. She was last hospitalized in August 1994 for removal of breast implants, which had been implanted in 1989. She testified that she was unable to work due to fatigue, headaches, and multiple joint pain and swelling due to an immune system deficiency as a result of silicon leaking from the implants. Stewart testified that she has headaches two to three times a month lasting on average three days and causing her to go to bed because of the nausea. Anti-inflammatory medications cause her stomach problems, aggravate a hiatal hernia, and aggravate her high blood pressure. She takes a large amount of medications which make her fatigue worse. She has constant pain in her joints, and has been unable to do any housework or cooking for the past year. She cannot balance a checkbook anymore or remember dates, and sometimes forgets her bath water so that it runs over on the floor. She has good and bad days, and on a bad day, she is in bed 18-24 hours. She cannot pick up a five pound bag of sugar.
In reaching this decision, the ALJ relied on the testimony of internal medicine specialist Lester L. Hibbett, M.D. over the findings of Stewart's examining physician, David A. McLain, M.D., a specialist in rheumatology. Dr. Hibbett testified that the Social Security regulations require objective findings of disability, and that he found no objective findings by Dr. McLain to support the conclusion that Stewart was disabled under the Social Security regulations. Dr. Hibbett opined that Dr. McLain probably diagnosed fibromyalgia based on Stewart's history of muscle pain/weakness which were subjective complaints, and on finding certain pressure points associated with the condition. Dr. Hibbett also explained that fibromyalgia is not a listed disability, so he (Hibbett) looked at equivalent conditions, all of which required positive laboratory tests, x-rays, and examination results which were not present in Stewart's records.
Dr. Hibbett equated fibromyalgia with rheumatoid arthritis, polymyositis, and dermatomyositis.
We review the Commissioner's decision to determine whether it is supported by substantial evidence and based upon proper legal standards. See McRoberts v. Bowen, 841 F.2d 1077, 1080 (11th Cir. 1988). We will not disturb the Commissioner's decision if, in light of the record as a whole, it appears to be supported by substantial evidence. See 42 U.S.C. § 405(g); MacGregor v. Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986). Substantial evidence is more than a scintilla and is such relevant evidence as a reasonable person would accept as adequate to support a conclusion. See Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 1427, 28 L.Ed.2d 842 (1971).
The law of this circuit is that the testimony of a treating physician must be given substantial or considerable weight unless "good cause" is shown to the contrary. Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997); MacGregor, 786 F.2d at 1053. The Commissioner's regulations also require that the findings of a treating physician be given controlling weight:
Generally, we give more weight to opinions from your treating sources, since these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of your medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultive examinations or brief hospitalizations.
20 C.F.R. § 404.1527(d)(2). Thus, the ALJ must clearly articulate the reasons for giving less weight to the opinion of a treating physician, and the failure to do so is reversible error. MacGregor, 786 F.2d at 1053.
We find that the ALJ erred as a matter of law in failing to provide any explanation for his rejection of the treating physician's opinion and diagnosis. The ALJ's decision did not provide sufficient reasons for rejecting an extensive report by Stewart's treating physician in which Dr. McLain outlined the signs and symptoms supporting his diagnosis of fibromyalgia and disability. Relying on the testimony of Dr. Hibbett, the ALJ reasoned that there was no objective clinical evidence on or prior to September 30, 1995, of a condition which could reasonably be expected to produce the level of pain, swelling, fatigue, nodules, nausea, elevated blood pressure or other symptoms which Stewart alleged. However, Dr. Hibbett's testimony does not contradict Dr. McLain's diagnosis. Moreover, Dr. Hibbet did not specialize in rheumatology, nor did he ever examine Stewart. Thus, we find reversible error in the ALJ's failure to give controlling weight to Dr. McLain's diagnosis and opinions, or to articulate reasons therefor.
Second, we question the ALJ's reliance on the absence of objective evidence of fibromyalgia to deny disability benefits. All the medical authorities agree that fibromyalgia is unique and can be extremely difficult to diagnose. The American College of Rheumatology has described fibromyalgia as:
. . . [a] syndrome [that] is a common form of generalized muscular pain and fatigue. The name "fibromyalgia" means pain in the muscles and the fibrous connective tissues (the ligaments and tendons). . . . Fibromyalgia is especially confusing and often misunderstood because almost all its symptoms are also common in other conditions. In addition, it does not have a known cause. . . . Unfortunately, because certain syndromes lack physical and laboratory findings (signs), but depend mostly on a person's report of complaints and feelings (symptoms), these syndromes are often viewed as not being real or important.
Arthritis Foundation American College of Rheumatology, Arthritis Information: Fibromyalgia (1992). Symptomatic patients are recommended to see a rheumatologist who is familiar with the diagnosis and treatment of the condition because not all doctors are trained to recognize the disorder. See id. Indeed, the Social Security Administration has acknowledged that the disease is not detectable through diagnostic tests but rather through medically accepted clinical techniques that show the existence of an impairment. See Memorandum from the Deputy Commissioner for Disability and Income Security Programs, to ALJ Verrell L. Dethloff (May 11, 1998). As explained by Chief Judge Posner of the Seventh Circuit:
[Fibromyalgia's] cause or causes are unknown, there is no cure, and, of greatest importance to disability law, its symptoms are entirely subjective. There are no laboratory tests for the presence or severity of fibromyalgia.
Sarchet v. Chater, 78 F.3d 305, 306 (7th Cir. 1996). Thus, a treating physician's determination that a patient is disabled due to fibromyalgia is even more valuable because there are no objective signs of severity and the physician must interpret the data for the reader.
See Frederick Wolfe, Disability and the Dimensions of Distress in Fibromyalgia, 1(2) J. Musculoskeletal Pain 64 (1993). Here, the ALJ discredited Stewart's testimony as to the severity of her joint pains and fatigue based in part on the lack of objective evidence in the record. In view of the fact that fibromyalgia by its very nature lacks objective evidence, the ALJ did not give sufficient reasons for finding that Stewart lacked credibility.
When proper weight is accorded to the reports of Dr. McLain and Stewart's other treating physicians, there is simply no substantial evidence supporting the Commissioner's decision. Medically accepted clinical techniques support Dr. McLain's diagnosis of fibromyalgia and his subsequent opinion that Stewart is totally disabled from any employment. The only conclusion we can reach based upon this record is that Stewart is entitled to compensation. Therefore, we REVERSE the opinion of the district court affirming the Commissioner's decision and REMAND with instructions that the case be returned to the Commissioner for the award of benefits.
Accepting the opinion of Stewart's treating rheumatologist as true, the Vocational Expert testified at the hearing before the ALJ that "there would not be any jobs [Stewart] could do" in the national economy.
REVERSED and REMANDED with instructions.